Miki Enami

Analysis of reasons for emergency call delays in Japan in relation to location: High incidence of correctable causes and the impact of delays on patient outcomes

REVIEW The interval between collapse and emergency call influences the prognosis of out-of-hospital cardiac arrest (OHCA). To reduce the interval, it is essential to identify the causes of delay. METHODS Basal data were collected prospectively by fire departments from 3746 OHCAs witnessed or recognised by citizens and in which resuscitation was attempted by emergency medical technicians (EMTs) between 1 April 2003 and 31 March 2008. EMTs identified the reasons for call delay by interview. RESULTS The delay, defined as an interval exceeding 2 min (median value), was less frequent in the urban region, public places and for witnessed OHCAs. Delay was more frequent in care facilities and for elderly patients and OHCAs with longer response times. Multiple logistic regression analysis indicated that urban regions, care facilities and arrest witnesses are independent factors associated with delay. The ratio of correctable causes (human factors) was high at care facilities and at home, compared with other places. Calling others was a major reason for delay in all places. Performing cardiopulmonary resuscitation (CPR) and other treatments was another major reason at care facilities. Large delay, defined as an interval exceeding 5 min (upper-quartile value), was an independent factor associated with a low 1-year survival rate. CONCLUSION The incidence of correctable causes of delay is high in the community. Correction of emergency call manuals in care facilities and public relation efforts to facilitate an early emergency call may be necessary. Basic life support (BLS) education should be modified to minimise delays related to making an emergency call.

The effects of the new CPR guideline on attitude toward basic life support in Japan

BACKGROUND There is no study regarding the influence of cardiopulmonary resuscitation (CPR) guideline renewal on citizens attitude towards all basic life support (BLS) actions. METHODS AND RESULTS We conducted a questionnaire survey to new driver licence applicants who participated in the BLS course at driving schools either before (January 2007 to April 2007) or after (October 2007 to April 2008) the revision of the textbook. Upon completion of the course, participants were given a questionnaire concerning willingness to participate in CPR, early emergency call, telephone-assisted chest compression and use of an automated external defibrillator (AED). After the revision, the proportions of positive respondents to use of AED as well as to all the four scenarios significantly increased from 2331/3564 to 3693/5156 (odds ratio (OR)=1.34) and from 1889/3443 to 3028/5126 (OR=1.18), respectively. However, the new guideline slightly but significantly augmented the unwillingness to make an early call (236/3568 vs. 416/5283, OR=0.83). Approximately 95% of respondents were willing to follow the telephone-assisted instruction of chest compression, while approximately 85% were eager to perform CPR on their own initiative. Multiple logistic regression analysis confirmed the results of mono-variate analysis, and identified previous CPR training, sex, rural area and student as other significant factors relating to attitude. CONCLUSIONS Future guidelines should emphasise the significance and benefit of early call in relation to telephone-assisted instruction of CPR or chest compression. The course instructors should be aware of the backgrounds of participants as to how this may relate to their willingness to participate.

Primary respiratory arrest recognised by emergency medical technicians and followed by cardiac arrest in Japan: Identification of a subgroup of EMT-witnessed cardiac arrests with an extremely poor outcome

REVIEW Some unconscious patients are found to be in primary respiratory arrest (PRA) by emergency medical technicians (EMTs). In contrast to citizens, EMTs manage PRA with artificial ventilation but not with cardiopulmonary resuscitation (CPR). This study aimed to investigate the characteristics and outcomes of PRA prior to EMT arrival and compare these data with those of a PRA-related group: patients with out-of-hospital cardiac arrests (OHCAs). METHODS Baseline data were prospectively collected by fire departments for their adult (16 years or older) OHCA and PRA patients from April 2003 through March 2010. We extracted those who had PRA prior to EMT arrival. The EMT- and bystander-witnessed OHCA patients who underwent CPR were also extracted as control groups. RESULTS There were 178 cases of PRA prior to EMT arrival. The majority (164/178) of these individuals were in a deep coma and met the criteria for the initiation of bystander CPR. Approximately 61% (108/178) of these PRAs were followed by cardiac arrests, which were classified as EMT-witnessed OHCAs by the Utstein template. The EMTs manually ventilated the patients until the cardiac arrest occurred. The 1-Y survival of this subgroup was the lowest of the PRA and PRA-related OHCA subgroups and was significantly lower than that of bystander-witnessed OHCAs with bystander CPR, when trauma and terminal illness cases were excluded (adjusted odds ratio=3.888 (1.103-24.827)). CONCLUSIONS We identified a subgroup of PRAs with unexpectedly poor outcomes. The BLS guidelines for healthcare providers including EMTs should be re-evaluated by a large prospective study.

Effects of obligatory training and prior training experience on attitudes towards performing basic life support: a questionnaire survey

To determine the effect of Japanese obligatory basic life support training for new drivers license applicants on their willingness to carry out basic life support.

In reply: Is out-of-hospital intubation by paramedics valid enough to be continued?

To the Editor:As Dr. Morita and his colleagues describe in their Letterto the Editor, many recent studies have shown that out-of-hospital intubation is associated with decreased survival[1–3]. However, there are differences in the medicalbackground of the endotracheal intubation (ETI) performedin these studies and our study.The incidence of ETI attempted by paramedics in thereported studies was extremely high ([80%) in the USA[1–3], with ETI attempted in patients with a difficult air-way or with a Cormack grade of C2[2]. In the regioncovered by our study, ETI is not permitted as a routineprocedure for patients with out-of-hospital cardiac arrest(OHCA). In addition, ETI attempts are terminated whenthe Cormack grade of patient is C2.The etiology of cardiac arrest may have differedbetween the patients in our study and those of the otherstudies. In none of the three studies [1–3] did the patientsshow an etiology of cardiac arrest. Approximately 60–70%of cardiac arrest is related to coronary heart disease in theUSA [4]. In our study, we showed that implementation ofETI may worsen the outcomes in OHCA patients with acardiac etiology, but they may improve the outcomes inOHCA patients without a noncardiac etiology.Finally, ETI was repeatedly attempted by paramedics inthe USA [2]. In our region, only two attempts are made.The interruption of chest compression accompanying theETI was set at\30 s prior to November 2006 and at\10 sthereafter.The Ontario pre-hospital advanced life support(OPALS) respiratory distress study showed that the intro-duction of an EMS advanced-life-support program signif-icantly reduced the mortality of patients with shortness ofbreath [5]. Japanese paramedics are allowed to performETI immediately after they witness a cardiac arrest. Webelieve that effectiveness of ETI should be prospectivelyevaluated in OHCAs that occur following the arrival of theparamedic.In our study, we excluded 124 patients in whomadvanced airway management (AAM) was discontinued orfailed. Of these 124 patients, 52 were managed by non-certified paramedics and did not include cases of attemptedETI. In the remaining 72 patients, certified paramedicsattempted either ETI or another AAM procedure, or both.Therefore, the 124 patients varied widely in terms of AAMprocedure and were justifiably excluded from the analysis.The AAM procedure was more frequently attempted bycertified paramedics. However, we showed that manage-ment by paramedics qualified for ETI was not independentfactor associated with sustained return of spontaneouscirculation.More than 50 or 60 intubations may be necessary toachieve a 90% success rate when the ETI is attemptedwithout considering the Cormack. According to a pre-liminary analysis in our region, after paramedics have had15 consecutive cases with Cormack grade of 1, the successrate in the following ten cases exceeds 95%. The trainingprograms are considered to be appropriate for the patientswith a Cormack grade of 1.The harm caused by ETI should be minimized by edu-cation and continuous quality assurance. In our region, arecertification program for certified paramedics has been